[Patellar osteochondral injury as onset of patellar instability]. / Lesión osteocondral patelar como debut de una inestabilidad rotuliana.

Patellar osteochondral fractures with no dislocation are uncommon and usually affect the centromedial facet of the patella. We present the case of a 10 year-old, overweight, female patient. She was seen in the emergency room after suffering an accidental fall, assessed as an osteochondral fracture-dislocation of the right patella with upper-outer displaced free fragments. By patient interview, she referred to no previous episodes of patellar dislocation. To complete the study, we performed an MRI which showed a medial facet patellar fracture, with two osteochondral fragments located in the sub-quadricipital recess, associated with other lesions suggesting patellar subluxation. We considered that the best treatment was surgery, so the following was performed: an open reduction and internal fixation with absorbable bars, lateral patellar release (Ficat technique), patellar coverage by medial portion of quadriceps (Insall technique) and internal moving of the lateral half of the patellar tendon (Goldwaith technique). The injury was checked one year later using arthroscopy. It confirmed a good reconstruction of the articular surface, and right patellar centering. At follow-up, during the physiotherapy period, the patient began to have repeated episodes of instability in the contralateral patella. The CT scan confirmed the patellar lateralisation (TAGT 17). Centering surgery was indicated due to the occurrence of multiple dislocation episodes. The patient currently carries out normal physical activity and she has a complete range of movement. Patellar osteochondral fracture is an injury frequently associated with patellar instability, which may onset in the first episode. The medial location of the lesions and the involvement of the system of medial knee stability is a fundamental finding. This fact reinforces the diagnosis of pre-fracture patellar dislocation. This is not a fracture-dislocation, but a dislocation-fracture. We may, therefore, treat the injury and its cause.

Lesión osteocondral patelar como debut de una inestabilidad rotuliana / Patellar osteochondral injury as onset of patellar instability

Las fracturas osteocondrales patelares sin luxación son infrecuentes, y suelen afectar a la faceta centromedial de la rótula. Presentamos el caso de una niña de 10 años con sobrepeso, que acude a urgencias después de sufrir una caída casual, valorándose como una fractura-luxación ostecondral rotuliana derecha con desplazamiento supero-externo. Al historiar la paciente, no refiere episodios previos de luxación rotuliana. Para completar el estudio, realizamos una resonancia magnética que objetiva una fractura osteocondral de faceta medial rotuliana desprendiéndose dos fragmentos que se sitúan en el receso subcuadricipital y lesiones sugestivas de subluxación rotuliana. Se efectúa la cirugía, realizándose reducción y osteosíntesis con barras reabsorbibles y recentraje rotuliano derecho mediante liberación lateral y traslación interna del hemitendón rotuliano externo según técnica de Goldthwaith. Una artroscopia de revisión confirma una buena reconstrucción y centraje rotuliano derecho. En el seguimiento, durante el período de rehabilitación, la paciente inicia episodios repetidos de inestabilidad en la rótula contralateral. Se realiza una tomografía computarizada que confirma la lateralización de la misma con una TAGT de 17. Al repetir estos episodios de inestabilidad, se indica un centraje rotuliano mediante las técnicas de Insall (disección del músculo vasto interno, cubriendo la rótula con el colgajo del mismo), Ficat (sección del alerón lateral externo), Goldwaith (traslación hacia metáfisis tibial superointerna del hemitendón rotuliano externo). La paciente, actualmente, realiza actividad física sin limitación y con un balance articular completo. La fractura osteocondral patelar es una lesión frecuentemente asociada a inestabilidad rotuliana, pudiendo debutar en el primer episodio. La localización medial de las lesiones y la afectación del sistema de estabilidad medial de la rodilla es un dato fundamental. Esto refuerza el diagnóstico de luxación patelar previa a la fractura osteondral, no es una fractura-luxación, sino una luxación-fractura. Debemos, por tanto, tratar la lesión y su causa (AU)

Patellar osteochondral fractures with no dislocation are uncommon and usually affect the centromedial facet of the patella. We present the case of a 10 year-old, overweight, female patient. She was seen in the emergency room after suffering an accidental fall, assessed as an osteochondral fracture-dislocation of the right patella with upper-outer displaced free fragments. By patient interview, she referred to no previous episodes of patellar dislocation. To complete the study, we performed an MRI which showed a medial facet patellar fracture, with two osteochondral fragments located in the sub-quadricipital recess, associated with other lesions suggesting patellar subluxation. We considered that the best treatment was surgery, so the following was performed: an open reduction and internal fixation with absorbable bars, lateral patellar release (Ficat technique), patellar coverage by medial portion of quadriceps (Insall technique) and internal moving of the lateral half of the patellar tendon (Goldwaith technique). The injury was checked one year later using arthroscopy. It confirmed a good reconstruction of the articular surface, and right patellar centering. At follow-up, during the physiotherapy period, the patient began to have repeated episodes of instability in the contralateral patella. The CT scan confirmed the patellar lateralisation (TAGT 17). Centering surgery was indicated due to the occurrence of multiple dislocation episodes. The patient currently carries out normal physical activity and she has a complete range of movement. Patellar osteochondral fracture is an injury frequently associated with patellar instability, which may onset in the first episode. The medial location of the lesions and the involvement of the system of medial knee stability is a fundamental finding. This fact reinforces the diagnosis of pre-fracture patellar dislocation. This is not a fracture-dislocation, but a dislocation-fracture. We may, therefore, treat the injury and its cause (AU)

Osteotomía de Pelet modificada en el tratamiento del hallux valgus juvenil / Modified Pelet osteotomy in the treatment of juvenile hallux valgus

Objetivo. Se presentan 61 casos de hallux valgus juvenil tratados quirúrgicamente mediante la técnica de Pelet modificada. Material y método. En el periodo comprendido entre 1996 y 2002 se han revisado 37 pacientes, 30 mujeres y 7 hombres, con unas edades comprendidas entre 9 y 19 años, promedio de 14 años, a los que se les practicó dicha técnica. El seguimiento mínimo fue de un año. En todos los casos se ha llevado a cabo una osteotomía subcapital del primer metatarsiano según la técnica descrita por Pelet, colocando como osteosíntesis una barra de material biorreabsorbible. Se autorizó la carga a las 24 horas. Resultados. Se ha conseguido la consolidación en un promedio de 5 semanas. En todos los casos se ha logrado una mejora de los ángulos intermetatarsiano y de hallux valgus con buen resultado clínico y pocas complicaciones. Conclusiones. Creemos que la osteotomía de Pelet es una técnica adecuada para el tratamiento del hallux valgus juvenil y del adolescente ya que es capaz de corregir las alteraciones patogénicas más frecuentes en estos pacientes, al mismo tiempo que nos parece poco agresiva (AU)

Purpose. Sixty-one cases of juvenile hallux valgus are presented that were treated surgically through a modified Pelet technique. Materials and methods. Between 1996 and 2002, 37 patients were subjected to the above mentioned technique (30 females and 7 males). Mean age was 14 years (range: 9-19). Minimum follow-up was one year. In all cases a subcapital osteotomy of the first metatarsal was carried out according to the technique described by Pelet. The osteosynthesis material used was a bioresorbable rod. Weight-bearing was allowed at 24 hours. Results. Healing was achieved at 5 weeks on average. In all cases an improvement was obtained in the intermetatarsal and hallux valgus angles, with good clinical results and few complications. Conclusions. We believe that Pelet osteotomy is suitable for the treatment of juvenile and adolescent hallux valgus since it is a non-aggressive technique that can correct the most usual pathogenetic alterations seen in these patients (AU)

[Congenital pseudarthrosis of the clavicle: a review of nine cases]. / Seudoartrosis congénita de clavícula.

BACKGROUND: Congenital pseudarthrosis of the clavicle (CPC) is a rare malformation of the scapular waist of unknown etiology. About 200 cases have been reported. The lesion is usually right-sided and unilateral. Physical examination reveals swelling over the midportion of the clavicle, usually asymptomatic, and the diagnosis is confirmed by plain radiology. The differential diagnosis includes posttraumatic pseudarthrosis, cleidocranial dysostosis and neurofibromatosis. Surgical treatment is indicated in symptomatic patients or those with major deformity. MATERIAL AND METHODS: We performed a retrospective review of the medical records of 9 patients with CPC managed in our hospital. RESULTS: We studied 5 girls and 4 boys with unilateral right CPC. None of them had a familial history of CPC. Four complained of local pain, without functional impairment, and clavicular asymmetry on x-ray ranging from 0.5 to 1 cm, without accompanying pathologic findings. Surgical treatment was performed in 5 patients, with resection of fibrous pseudarthrosis, internal fixation, and iliac bone graft. In 4 patients callus response was achieved at 2 months. The remaining patient required withdrawal of orthopaedic material 2 months after surgery because of its protrusion through the skin, without the need for further surgical treatment to date. CONCLUSIONS: Although rare, CPC should be included in the differential diagnosis of clavicle abnormalities in children. Good results are achieved with current surgical techniques in patients with clear indication.

Seudoartrosis congénita de clavícula / Congenital pseudarthrosis of the clavicle: a review of nine cases

Antecedentes: La seudoartrosis congénita de clavícula (SCC) es una malformación rara de la cintura escapular de etiología incierta de la que se han descrito unos 200 casos. Suele ser unilateral, con afectación mayoritaria del lado derecho. Se presenta en forma de tumoración en el tercio medio clavicular, generalmente asintomática. La radiología simple confirma el diagnóstico. El diagnóstico diferencial incluye principalmente la seudoartrosis postraumática, la disostosis cleidocraneal y la neurofibromatosis. El tratamiento quirúrgico debe indicarse en aquellos casos sintomáticos o con gran defecto estético. Material y métodos: Revisión retrospectiva de las historias clínicas de los 9 pacientes afectados de SCC controlados en nuestro centro. Resultados: Son 5 niñas y 4 niños, con afectación unilateral del lado derecho. Ninguno presenta historia familiar de SCC. Refieren dolor cuatro, sin limitación funcional. Radiológicamente la asimetría clavicular oscila entre 0,5 y 1,5 cm, sin otros hallazgos asociados. Un total de cinco han sido intervenidos quirúrgicamente, con resección de los extremos seudoartrósicos, osteosíntesis e injerto de hueso ilíaco autólogo. Los resultados son satisfactorios con consolidación de la lesión a los 2 meses en 4 niños; la paciente restante precisó la retirada del material debido a su protrusión sobre la piel a los 2 meses, sin precisar por el momento una nueva reintervención. Conclusiones: La SCC, pese a ser una entidad de rara presentación, debe formar parte del diagnóstico diferencial de las afecciones claviculares en los niños. Las técnicas quirúrgicas actuales ofrecen buenos resultados para aquellos casos en que esté indicado

Background: Congenital pseudarthrosis of the clavicle (CPC) is a rare malformation of the scapular waist of unknown etiology. About 200 cases have been reported. The lesion is usually right-sided and unilateral. Physical examination reveals swelling over the midportion of the clavicle, usually asymptomatic, and the diagnosis is confirmed by plain radiology. The differential diagnosis includes posttraumatic pseudarthrosis, cleidocranial dysostosis and neurofibromatosis. Surgical treatment is indicated in symptomatic patients or those with major deformity. Material and methods: We performed a retrospective review of the medical records of 9 patients with CPC managed in our hospital. Results: We studied 5 girls and 4 boys with unilateral right CPC. None of them had a familial history of CPC. Four complained of local pain, without functional impairment, and clavicular asymmetry on x-ray ranging from 0.5 to 1 cm, without accompanying pathologic findings. Surgical treatment was performed in 5 patients, with resection of fibrous pseudarthrosis, internal fixation, and iliac bone graft. In 4 patients callus response was achieved at 2 months. The remaining patient required withdrawal of orthopaedic material 2 months after surgery because of its protrusion through the skin, without the need for further surgical treatment to date. Conclusions: Although rare, CPC should be included in the differential diagnosis of clavicle abnormalities in children. Good results are achieved with current surgical techniques in patients with clear indication